NHS FIFE
Report to the Audit Committee on 16 th May 2013
PAYMENTS TO PRIMARY CARE PRACTITIONERS
1. INTRODUCTION
1.1 The expenditure budget for Primary Care Practitioners (PCPs) in Fife for 2012/13 is
£86million (excluding Prescribing). Ensuring that payments made to PCPs on behalf of (and charged to) NHS Fife are accurate and valid is a key element of financial control in the use of resources in NHS Fife. This report provides the Audit
Committee with an update on the current status of these payments at the end of financial year 2012/13 and the monitoring arrangements in place.
1.2 NHS Fife continues to meet routinely with representatives from Practitioner Services
Division (PSD) to monitor the payment verification work undertaken by PSD on behalf of the health board. Finance representation at these meetings ensures any significant issues are communicated to the Assistant Director of Finance
(Management Accounting). Separate reports are produced and meetings held for the four different independent contractor payment streams
– General Medical
Practitioners, Ophthalmic, Dental and Pharmacy. Outcomes and issues arising from these discussions are documented in this report.
1.3 Payment Verification Procedures
– Circular CEL 16 (2012) was issued this year notifying the revised payment verification protocol for Primary Medical Services.
This protocol was accepted by the Scottish Government and Audit Scotland. The
Fife PV Review Group, which includes representatives from both PSD and NHS
Fife, ensures that procedures are in place to implement the protocol to give assurance to the Board of the validity and accuracy of payments.
2. PAYMENT VERIFICATION REPORTS – GENERAL MEDICAL SERVICES
2.1 PV reports have been received quarterly as planned, with actions agreed in conjunction with NHS Fife staff and carried out with no significant issues arising.
Assurances have been given on the verification exercises as in previous years. Key issues discussed at recent meetings include:

Global Sum Payments - The Registration and Data Quality teams within PSD carry out many day-to-day tasks where the primary objective is not payment verification. These tasks however enhance the quality of data held on the CHI, and hence improve the accuracy of the Global Sum payment.

Additional Services
– The payment verification of Additional Services relates specifically to the areas of Contraceptive, Minor Surgery and
Immunisations/Vaccinations. This is carried out as part of an
Additional/Enhanced Services practice visit. Each financial year, 3% of practices are selected randomly to receive this type of visit. In addition, targeted visits may be carried out where appropriate. Reports for quarter ending December 2012 were discussed at the PV meeting on 23rd January 2013. Flu claims were
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discussed with actions agreed at this meeting and as a result 15 recoveries and 2 payments will be authorised by NHS Fife totalling a net
£438, relating to flu claims. No other issues were identified.
2.2 The pre-payment verification of the Quality and Outcomes Framework (QOF) is comprised of three key processes to ensure the following:


The requirements of the clinical indicator have been met.
The application of exception coding has been carried out as required. CEL
14 (2012) dated April 2012 draws attention to publication of detailed supplementary guidance on exception reporting for QOF. The guidance is

Scotland-specific but does not replace the existing guidance on the application of exception coding PCA(M)(2006) 15 - New Guidance of
Exception Reporting, October 2006.
The achievement of organisational indicators can be appropriately evidenced.
2.3 The above processes are carried out during practice visits. In total, 5% of practices are selected randomly each financial year, and in addition targeted visits may be carried out if deemed appropriate.
3.
DIRECTED ENHANCED SERVICES
3.1 NHS Circular PCA(M)(2011)13 confirmed the continuance of funding arrangements of Directed Enhanced Services (DES) for 2012/13.
There are currently 6 DES in place in NHS Fife for which the Scottish Government sets the payment rates.

Palliative Care

Minor Surgery

Services to staff dealing with violent patients

Childhood Immunisations

Influenza Pneumococcal and Pertussis immunisation

Extended Hours
3.2 The key changes from the previous year are that all pregnant women from 28-38 weeks are to be offered and (where accepted) provided with a vaccination to protect their babies against pertussis. Vaccination against pertussis should be provided for all pregnant women from 28 weeks onwards. The optimal time is in the period weeks 28 to 32 (inclusive).
3.3 Childhood Immunisation, Influenza and Pnuemococcal and Pertussis Immunisation, and Extended Hours will continue and be reviewed for 13/14. In 12/13 Osteoporosis and Extended hours (nursing provision) ceased as DES provisions.
3.4 During 2012/13 the number of practices providing the Extended Hours service increased to 38 out of 58 compared to 32 in the previous year.
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4. SCOTTISH ENHANCED SERVICES PROGRAMME
4.1 The programme of Enhanced Services commenced in 2008/09 and following review of each service has continued in 2012/13 . The funding for the period was £785k and includes the following:

Closer/Integrated Working with GP practices - A Shared Care Service commenced in 2012 and is intended to support shared and integrated working between primary and secondary care. 51 of 58 practices provide this service
(88%).

Care Homes - A wide ranging review of the delivery of care to patients in Care
Homes was completed and the Enhanced Service has been redesigned in order to improve the quality of care provided. 53 of 58 practices provide this service
(91%).

Care of Adults with Diabetes - This service has also been redesigned and is intended to support the shift of diabetes care from Acute to Primary Care. 40 of
58 practices provide this service. (69%).

COPD - This service has discontinued in 2012 and has been replaced by the
Integrated working Care Share Service.
5. QUALITY AND OUTCOMES FRAMEWORK (QOF)
5.1 The total number of points available has remained the same in total for all Practices, totalling 1000 points for each Practice. There have been no amendments to the
QOF in the last financial year.
5.2 The table below provides a summary of points available, split by Category.
QOF Points Value
Domain
Clinical
Organisational
Quality & Productivity
Points
661
165.5
96.5
Patient Experience
Additional Services
33
44
TOTAL 1000
6. PRE-PAYMENT VERIFICATION QOF PAYMENTS
6.1 QOF Calculator is the software system that collects and calculates practice
performance and is signed off as complete by the practices by 17 th May 2013. NHS
Fife completes the QOF reviews and approves practice achievement by 14 th June;
achievement payments are made to the practices on 29 th June.
6.2
The Scottish Quality Prescribing Initiative ( SQPI) results will be reviewed by the
Board and results informed to PSD by 26 th July. Payments will then be recalculated and any recoveries made at the end of August.
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6.3 The QOF Dashboard facility has been added to QOF Calculator. All Health Boards
and Practices will have access to a reporting suite to allow them to effectively
monitor their progress against QOF indicators. The reports will allow the practices
to analyse the data provided and allow then to draw comparisons with similar
benchmarked practices.
7. OPHTHALMIC / DENTAL PAYMENTS
7.1 A meeting of the Review Group for Ophthalmic/Dental Services was held on 2 April
2013 for quarter ending December 2012.
Ophthalmic Payments:
7.2 The report was discussed and it was noted that claim levels remain broadly consistent with the previous year. The number of claims received for quarter ending
31 December 2012 (3 quarters) was 42,520, largely for eye examinations (78%).
7.3 The Ophthalmic Review Team has completed the cycle of Practice visits and the report now includes analysis of the visits.
7.4 Follow up of any outliers is carried out by the Ophthalmic Advisers. To date, no significant issues have arisen
Dental Payments:
7.5 The report for the Quarter ended December 2012 was presented and discussed in detail by the PV Review Group on the 28 th March. On-going cases were discussed and assurance given that the necessary checks were in place and any required investigations were being undertaken. Post Treatment Reports on referrals to the
Scottish Dental Reference Service (SDRS) are a key element of the PV process within Dental.
7.6 The Review Group noted that the number of post treatment referrals from NHS Fife remains consistent with previous years. For the nine months to December 2012 a total of 177 referrals were made to the SDRS from Fife. Of this, 5% were nonrandom referrals requested by the health board based on information presented by
PV on outliers. The figures below summarise the information returned from the
SDRS on these appointments:

37 reports issued

64 failed appointments

28 referral cancelled

48 reports due
Fife
20.9%
36.2%
15.8%
27.1%
Scotland
12.7%
27.7%
12.6%
47.0%
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7.7 For the nine months to December 2012, 127 post-treatment reports have been completed (many of which relate to the prior financial year), and of these:

92 were grade 1

31 were grade 2

4 were grade 3

0 were grade 4
Gradings are based on the following:

Grade 1 – Completely satisfactory – no further action

Grade 2 – Satisfactory – no further action

Grade 3 – Unsatisfactory – Dentist to receive further referrals

Grade 4 – Completely unsatisfactory – increased level of referrals
7.8 The Review Group were content that all cases were being progressed in line with the protocols in place.
8. PHARMACY PAYMENTS
8.1 A meeting of the Pharmacy Review Group was held on 15 th April 2013, and the reports for the quarter ending September 2012 were considered.
8.2 After discussion at a national level, risk categories targeted by the PV team for particular scrutiny in 12/13 are:









Public Health Service
Public Health Service
MAS
CMS
– Nicotine Replacement Therapy (NRT)
– Emergency Hormonal Contraception (EHC)
Out of Pocket Expenses (OOPE)
Stoma
Influenza Vaccination Programme (seasonal)
Methadone
Random Sampling
8.3 PV check levels are as follows:
Level 1 The payments system will automatically carry out 100% checks on the payments.
Level 2 Level 2 consists of the compilation and analysis of statistical information, which will be reported to NHS Boards on a quarterly basis.
Level 3 Further investigations are undertaken as a result of outputs from level
2 checks.
Level 4 PV will undertake a check on randomly selected items for each NHS
Board.
8.4 Level 2 reports were reviewed and two pharmacies were investigated where they were outliers for Out Of Pocket Expenses – no issues arose from this. Also, various
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contractors are to be monitored in relation to Stoma payments over the next two quarters.
8.5 The Level 3 reports were reviewed and findings from one of these reports, where issues did arise, are summarised below.
 “No Instalment Requested” – 56 Omeprazole 20mg capsules and 300
Paracetamol 500mg tablets were prescribed, however no instalment dispensing was requested by the Prescriber. The Contractor endorsed the medication with weekly instalments, resulting in higher payments to the Pharmacy compared to monthly dispensing.

PV requested the appropriate Patient Medication Record for this prescription, which confirmed that the drugs were to be dispensed by weekly instalments.
 “Cost Effective” – 1 item – 300 Paracetamol 500mg tablets were prescribed, which are available in pack sizes of 32 and 100 tablets. The Contractor endorsed the prescription using the 32 tablet pack size. However, the 100 tablet pack size would have been more economical for the NHS Board (£3.99 versus
£9.75).

PV requested the appropriate PMR for this prescription, which confirmed that the Contractor had used the 32 tablet pack size for dispensing 336 tablets.
However, it should be noted that this item was also dispensed weekly so required 42 tablets on each occasion.
8.6 Cross Border Flow (CBF):
PV extracted data on the number of prescriptions that have been prescribed by
NHS Fife Prescribers and dispensed in other NHS Board areas. The NHS Board requested that PV investigate the number of prescriptions being prescribed by an outlier pharmacy and dispensed in NHS Forth Valley. Consequently these items appear to be legitimate cross border flow prescriptions which were dispensed for
Care Home patients.
Community Pharmacy Contract
8.7 The implementation of the new Community Pharmacy Contract began in July 2006 to introduce four new services to the pharmacy contract:

Minor Ailments Service (MAS)

Public Health Service (PHS)

Acute Medication Service (AMS)

Chronic Medication Service (CMS)
8.8 The first two elements (MAS and PHS) were introduced in July 2006. AMS was introduced in February 2010 allowing electronic transfer of prescriptions data between GP systems and Pharmacies by use of a bar code system. NHS Fife now has 55 Community Pharmacies scanning 90% of prescriptions.
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8.9 CMS was implemented on 11 th May 2010. This service provides personalised pharmaceutical care by a pharmacist to patients with long term conditions. Within
Fife all 84 pharmacies now have registered patients undertaking review of medicines and completion of Care Plans. NHS Fife was an early adopter of this service and has 12 pharmacies and 10 GP practices able to deliver the serial prescribing element of CMS. All GP practices and community pharmacies must be able to deliver the service by December 2013 and work is ongoing to provide support and training to all sites to increase uptake over the coming months.
8.10 The total NHS Fife Community Pharmacy expenditure for 2012/13 including the above services was £11.5m.
9. COUNTER FRAUD SERVICES (CFS)
Review of Estimated Fraud / Error in FHS Income
9.1 The role of NHS Counter Fraud Services (CFS) encompasses all services within the
NHS in Scotland.
9.2 Throughout 2012/13, CFS has continued in a programme of visits and publicity to raise awareness of CFS and the role it fulfils.
9.3 NHS Fife receives monthly update reports from CFS which come directly to the
Board’s Fraud Liaison Officer (FLO) to be actioned and followed up as appropriate with the responsible individuals. The most recent report which was received on the
8 th April 2013 indicates that there are currently three open cases relating to NHS
Fife.
9.4 CFS also provides Boards with an annual quantitative analysis of the estimated level of fraud/error and an extrapolated potential fraud/error in respect of patient exemption checking. The methodology for extrapolation was revised by ISD in
2006 in agreement with the CFS Steering Group.
Estimated Fraud/Error year year
2012 2011
%
£’000
%
£’000
Dental
Ophthalmic
6.1
3.2
245
57
5.7
3.6
203
55
9.5 Figures for estimated fraud within Ophthalmic and Dental are broadly comparable with the previous year. Note there is no measure of potential fraud within Pharmacy due to the ending of prescription charges from April 2011.
9.6 For information, the attached appendix provides a summary of the recoveries by
CFS on behalf of NHS Fife and NHS Scotland via the Patient Exemption Checking
Process.
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10. RECOMMENDATION
10.1 The Audit Committee is asked to:
 Note the contents of this position report and that further reports will be brought forward as necessary.
ANDREW McCREADIE
Assistant Director of Finance
(Management Accounting)
JACQUELINE WATSON
Primary Care Accountant
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